Clinical Pearls: Syncope

I'm doing a new thing here. I'm listening to medical podcasts on the way to work, so I'm going to try and share some of the pearls of clinical wisdom I pick up. The sources are a variety of free podcasts available through iTunes.

If you're an experienced provider, you've probably (like me) forgotten a lot of the nifty bits of clinical information that you were taught in school but didn't NEED to know. The stuff that got lost when you were cramming NREMT and ACLS skill sheets in your head. The stuff that might actually be more useful now that you're out in the field.

So that's what I'll try and bring you: Short, sweet tidbits that can help the experienced (or new) provider up their game.

We see syncope a lot. A lot of it is (or seems) harmless, and many of us like to wastebasket it into the vasovagal category, and don't mind getting a refusal.

Try to be more suspicious. Don't get suckered by how good they look now. Think about the patho. If it's not a seizure or low blood sugar, it's probably not enough blood or oxygen getting to the brain. Arrythmias? Stroke? Aortic stenosis or dissection? Occult (you know, hidden) bleed? Pulmonary embolism? There are some big, scary bears that cause syncope, and you should suspect them before you call it a vagal or psychogenic.

But how do you make that judgement? What should worry you?

First, most of these folks warrant a good assessment. Get a real detailed history. Find out if they had symptoms before they syncopized. Get a good set of vitals, and a 12 lead ECG is an excellent idea. Check neuros. Ask friends and family if they are acting normal. Go LOOKING for trouble.

But who are the folks to be worried about?

• Patients with chest or back pain, new onset, before or after the syncope, should be concerning for aortic aneurysm or dissection, or PE, or cardiac causes.

• Patients who don't return to their baseline after a syncope should be concerning for intracranial pathology (CVA/TIA/bleed).

• And patients who have no prodrome, no symptoms before passing out, no dizziness or tunnel vision, those folks should have you worried about weird rhythms.

Vasovagal syncope is not uncommon -- but just like anxiety attack, it should be a (presumptive, field) diagnosis of exclusion, the one you reach after everything else has been exhausted.

Hope this is helpful to some of y'all. More coming soon!